accreditation process col pawan kapoor1
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ACCREDITATION PROCESS
By
Col (Dr) Pawan Kapoor
MBBS(AFMC), MHA(AIIMS)DNB ( H&HA), MMS (Osmania), MBA (IGNOU)
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GOOD NEWSGOOD NEWS
I AM NOT GOING TO BORE YOU
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BAD NEWSBAD NEWS
YOU WILL STILL HAVE TO
TOLERATE ME
FOR THE NEXT FEW HOURS
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THE GOOD NEWSTHE GOOD NEWS
Our clientele now knows the importanceOur clientele now knows the importance
of Good Health and values itof Good Health and values it
THE BAD NEWSTHE BAD NEWS Our clientele now knows the importanceOur clientele now knows the importance
of Good Health and values it ANDof Good Health and values it AND----------
NOW HAS EXPECTATIONSNOW HAS EXPECTATIONS
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AS A PATIENT WHAT QUALITYAS A PATIENT WHAT QUALITY
LEVELS WOULD YOU ACCEPT FROMLEVELS WOULD YOU ACCEPT FROMYOUR HEALTH SERVICESYOUR HEALTH SERVICES??
90%90%
95%95%
96%96%
98%98%
99%99%
99.9%99.9%
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IF 99.9% IS ACCEPTABLE TO YOU, THEN
YOUR HEART FAILS
TO BEAT 32,000TIMES EACH YEAR
* 20,000 WRONG
DRUGPRESCRIPTIONS
MADE EVERY YEAR
* 500 SURGICALOPERATIONS AREPERFORMED
WRONGLYEVERY WEEK
* 19,000 BABIES AREDROPPED BY
DOCTORSAT BIRTH
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WELL ........
THERE IS ONLY A 1 %
DIFFERENCE IN THE DNA
GENETIC CODE BETWEEN A
CHIMPANZEE AND A
HUMAN BEING
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IN OUR PROFESSION THERE IS NO SCOPE
FOR ERROR. FOR ANY ERROR COMMITTED
IS ALL THE DIFFERENCE BETWEEN
LIFE AND DEATH, BETWEEN RELIEF AND
DISABILITY
THERE IS NO SECOND CHANCE
Then ..
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HOW TO ACHIEVEHOW TO ACHIEVE
EXCELLENCE IN HEALTHEXCELLENCE IN HEALTH
Pleasewait..
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WHAT IS QUALITY ?WHAT IS QUALITY ?
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Appropriate application of medical Appropriate application of medical
knowledge with due regard to theknowledge with due regard to the
balance between the hazard inherentbalance between the hazard inherent
in every medical intervention and thein every medical intervention and the
benefits expected from itbenefits expected from it
It is, however more complex thanIt is, however more complex thanthis.this.
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QUALITY FROM WHOSEQUALITY FROM WHOSE
POINT OF VIEW ?POINT OF VIEW ?
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Provider of Health care ServicesProvider of Health care Services
Recipient of the Health careRecipient of the Health care
servicesservices
Organizer of the Health careOrganizer of the Health care
servicesservices
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PROVIDERS CONCERNSPROVIDERS CONCERNS To provide care as per establishedTo provide care as per established
normsnorms
Adequate resourcesAdequate resources
Self satisfaction with the finalSelf satisfaction with the final
outcomeoutcome
Should contribute to enhancement ofShould contribute to enhancement of
skills, competence and add toskills, competence and add to
experienceexperience
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RECIPIENTS CONCERNSRECIPIENTS CONCERNSAccessibility
Affordability Prompt attention
Less waiting time Early diagnosis and cure
Return to Productivity as early as possible Humane Treatment ie to be treated with
empathy , respect and concern
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ORGANISERS CONCERNSORGANISERS CONCERNS
Responsible to the Society for the fundsResponsible to the Society for the funds
spent on health carespent on health care
To ensure safety of public and preventTo ensure safety of public and prevent
inappropriate or suboptimal careinappropriate or suboptimal care
To meet the requirements of the recipientTo meet the requirements of the recipient
and provider of the health care services atand provider of the health care services at
Acceptable costsAcceptable costs
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SIMPLE MEANING OFSIMPLE MEANING OF
QUALITYQUALITY
Simply defined Quality is the degree ofSimply defined Quality is the degree of
adherence toadherence to predetermined standardspredetermined standardsbased on existing knowledge, principlesbased on existing knowledge, principles
and practicesand practices
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What are Standards
A standard is a statement that defines the
structures and processes that must be
substantially in place in an organization to
enhance the quality of care
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COP.3COP.3The ambulance services areThe ambulance services are
commensurate with the scopecommensurate with the scope
of the services provided by theof the services provided by the
organizationorganization
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How to Measure the
standard ???
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Objective Elements
Objective element is a measurable
component of a standard
Acceptable compliance with objective
elements determines the overall
compliance with a standard
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COP.3COP.3
The ambulance services areThe ambulance services arecommensurate with the scopecommensurate with the scope
of the services provided by theof the services provided by theorganizationorganization
Objective elementsObjective elementsa)a) There is adequate access and space forThere is adequate access and space for
the ambulance(s)the ambulance(s)
b)b) Ambulance(s) is appropriately equippedAmbulance(s) is appropriately equipped
c)c) Ambulance(s) is manned by trained Ambulance(s) is manned by trained
personnelpersonnel
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contcont
d)d) There is a checklist of all equipment andThere is a checklist of all equipment and
emergency medicationsemergency medications
e)e) Equipment are checked on a daily basisEquipment are checked on a daily basis
f)f) Emergency medications are checkedEmergency medications are checked
daily and prior to dispatchdaily and prior to dispatch
g)g) The ambulance(s) has a properThe ambulance(s) has a proper
communication systemcommunication system
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COP.4COP.4
Policies and procedures guidePolicies and procedures guidethe care of patients requiringthe care of patients requiring
cardiocardio--pulmonary resuscitationpulmonary resuscitation Objective elementsObjective elements
a)a) Documented policies and proceduresDocumented policies and proceduresguide the uniform use of resuscitationguide the uniform use of resuscitation
throughout the organizationthroughout the organization
b)b) Staff providing direct patient care isStaff providing direct patient care istrained and periodically updated intrained and periodically updated in
cardio pulmonary resuscitationcardio pulmonary resuscitation
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contcont
c)c) The events during a cardioThe events during a cardio--pulmonarypulmonary
resuscitation are recordedresuscitation are recorded
d)d) An analysis of all cardiac arrests is doneAn analysis of all cardiac arrests is done
e)e) A multidisciplinary committee monitors A multidisciplinary committee monitors
the effectiveness of cardiothe effectiveness of cardio--pulmonarypulmonary
resuscitationresuscitation
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WHAT IS ACCREDITATIONWHAT IS ACCREDITATION
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Accreditation is an external review ofAccreditation is an external review of
quality with four principal components:quality with four principal components:
It is based on written and publishedIt is based on written and published
standardsstandards
Reviews are conducted by professionalReviews are conducted by professional
peerspeers The accreditation process isThe accreditation process is
administered by an independent bodyadministered by an independent body The aim of accreditation is to encourageThe aim of accreditation is to encourage
organizational development.organizational development.
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Objectives of AccreditationObjectives of Accreditation
Assess Quality and Safety of CareAssess Quality and Safety of Care
Assess a HCO ability to ensure continuousAssess a HCO ability to ensure continuousimprovement in Qualityimprovement in Quality
Formulate Explicit RecommendationsFormulate Explicit Recommendations Involve professionals at all stages of theInvolve professionals at all stages of the
quality initiativequality initiative
Provide external recognition of the QualityProvide external recognition of the Qualityof care in the HCOof care in the HCO
Improve public confidenceImprove public confidence
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What Accreditation begets ?What Accreditation begets ?
Customer focusCustomer focus
Competitive advantageCompetitive advantage
Corporate environmentCorporate environment
Confidence of Regulatory and payingConfidence of Regulatory and paying
authoritiesauthorities
MinimisationMinimisation of litigation lossesof litigation losses
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Making of standardsMaking of standards
Patient SafetyPatient Safety
Staff and employee safetyStaff and employee safety
Environment and community safetyEnvironment and community safety
Information Education and CommunicationInformation Education and Communication
Simple and easy to comprehendSimple and easy to comprehend
MeasurableMeasurable
AchievableAchievable
Organized around important functionsOrganized around important functions
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What are the Important
functions ???
Patient Centered functionsPatient Centered functions
Organisation Centered functionsOrganisation Centered functions
Community Centered functionsCommunity Centered functions
Environment Centered functionsEnvironment Centered functions
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BENEFITS OF ACCREDITATIONBENEFITS OF ACCREDITATION
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Benefits for PatientsBenefits for Patients High quality of careHigh quality of care
Credentialed and privileged medicalCredentialed and privileged medicalstaffstaff
Access to a quality focusedAccess to a quality focused
organizationorganization
Rights are respected and protectedRights are respected and protected
Understandable education andUnderstandable education andcommunicationcommunication
Patient Satisfaction is evaluatedPatient Satisfaction is evaluated
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Benefits for Patients Contd..Benefits for Patients Contd..
Involvement in care decisions andInvolvement in care decisions and
care processcare process
Focus on patient safetyFocus on patient safety
Pain managementPain management
Vulnerable patientVulnerable patient
Safe transportSafe transport
Continuity of careContinuity of care
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Benefits for the staffBenefits for the staff Improves professional staffImproves professional staff
developmentdevelopment
Provides education on consensusProvides education on consensus
standardsstandards
Provides leadership for qualityProvides leadership for qualityimprovement within medicine andimprovement within medicine and
nursingnursing
Increases satisfaction with continuousIncreases satisfaction with continuous
learning, good working environment,learning, good working environment,
leadership and ownershipleadership and ownership
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Benefits for the HospitalBenefits for the Hospital
Improves care
Stimulates continuous improvement
Demonstrates commitment to quality
care
Raises community confidence
Opportunity to benchmark with the
best
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Benefits to the CommunityBenefits to the Community
Quality revolutionQuality revolution
Disaster preparednessDisaster preparedness
-- epidemicsepidemics
-- physicalphysical
Access to comparative databaseAccess to comparative database
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MAKING OF STANDARDS
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Technical Committee Members
Col (Dr) Pawan Kapoor (Armed ForcesCol (Dr) Pawan Kapoor (Armed Forces
Medial Services)Medial Services)-- ConvenorConvenor
Dr Umesh Gupta (Vascular Surgeon & HeadDr Umesh Gupta (Vascular Surgeon & Head
of QI, Indraprastha Apollo Hospital)of QI, Indraprastha Apollo Hospital)
DrDr BidhanBidhan Das (COO, Rockland Hospital)Das (COO, Rockland Hospital)
DrDr SidharthSidharth Satpathy (Addl Prof of HA,Satpathy (Addl Prof of HA,
AIIMS)AIIMS)
Dr S Murali (Neurologist & Clinical CoDr S Murali (Neurologist & Clinical Co--ordinaterordinater, Manipal Hospital), Manipal Hospital)
Mr DeepakMr Deepak BandhopadhyayBandhopadhyay (Quality(Quality
Consultant)Consultant)
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METHODOLOGY FOLLOWED
Technical committee set up by QCITechnical committee set up by QCI
Review of existing global standardsReview of existing global standards
Perusal of available compliance dataPerusal of available compliance data
Applicability aspects to Indian contextApplicability aspects to Indian context
Amenable to international recognitionAmenable to international recognition
Not too difficult and stringent nor veryNot too difficult and stringent nor very
easy to achieveeasy to achieve MinimiseMinimise PrescriptivenessPrescriptiveness
ConsensusConsensus
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METHODOLOGY FOLLOWED
Draft standards forwarded to 32 ExpertsDraft standards forwarded to 32 Experts
across the countryacross the country
Feedback received incorporated wherever itFeedback received incorporated wherever it
was found to be feasible and implement ablewas found to be feasible and implement able
Pilot studyPilot study
Firming of the standardsFirming of the standards PublicationPublication
SensitisationSensitisation WorkshopsWorkshops
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METHODOLOGY FOLLOWED
Training of AssessorsTraining of Assessors
Laying Down of Guideline ManualsLaying Down of Guideline Manuals
ImplementationImplementation
Feedback from Assessors, Organisations,Feedback from Assessors, Organisations,
Consumers, stakeholdersConsumers, stakeholders
RevisionRevision
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NABH Standards
10 Chapters10 Chapters
100 Standards100 Standards
503 Objective Elements (512 in Revised503 Objective Elements (512 in Revised
EdnEdn
2007)2007)
Section I:Section I:
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Section I:Section I:
PatientPatient--Centered StandardsCentered Standards
3193193173176060TotalTotal
464644440909Hospital Infection ControlHospital Infection Control
303029290505Patients Rights andPatients Rights and
EducationEducation
616161611313Mgmt of MedicationsMgmt of Medications
1041041051051818Care of PatientsCare of Patients
787878781515Access, Assessment andAccess, Assessment andContinuity of CareContinuity of Care
REVREVOEOEStdStdDescriptionDescription
Section II:Section II:
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Section II:Section II:
Organisation Centered StandardsOrganisation Centered Standards
1931931861864040TotalTotal
414141410707Information Mgmt SystemInformation Mgmt System
474747471313Human Resource MgmtHuman Resource Mgmt
414141410909Facility Mgmt & SafetyFacility Mgmt & Safety
252520200505Responsibilities of MgmtResponsibilities of Mgmt
393937370606Continuous QualityContinuous QualityImprovementImprovement
REVREVOEOEStdStdDescriptionDescription
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Accreditation ProcessAccreditation Process
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WHO CAN APPLYWHO CAN APPLY
Any Health Care OrganisationAny Health Care Organisation
RequirementsRequirements
Currently in operation as a HCOCurrently in operation as a HCO
Preferably registered or licensedPreferably registered or licensed
Willing to assume responsibility for improvingWilling to assume responsibility for improving
quality of carequality of care Should be able to meet the prescribedShould be able to meet the prescribed
standards of the accrediting organisationstandards of the accrediting organisation
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HOW CAN ONE APPLYHOW CAN ONE APPLY
Organisations apply on prescribed formatOrganisations apply on prescribed format
giving details as requiredgiving details as required
Submission of a self assessment formSubmission of a self assessment form
indicating the outcomes of its QMS andindicating the outcomes of its QMS and
Internal AuditsInternal Audits
Extent of adherence to the laid downExtent of adherence to the laid down
standardsstandards
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SCREENING OF APPLICATIONSSCREENING OF APPLICATIONS
CompletenessCompleteness
AccuracyAccuracy
Clarifications sought if requiredClarifications sought if required
PREASSESSMENT SURVEYPREASSESSMENT SURVEY
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PREASSESSMENT SURVEYPREASSESSMENT SURVEY
To ascertain the readiness of theTo ascertain the readiness of theorganisation for Accreditationorganisation for Accreditation
Overview of the organizationalOverview of the organizationalpreparedness and commitment to qualitypreparedness and commitment to qualitygoals and consonance to laid downgoals and consonance to laid down
standardsstandards Deficiencies noticed informed to theDeficiencies noticed informed to the
organisationorganisation
Advice rendered on the methodology to beAdvice rendered on the methodology to befollowed during the Accreditation Surveyfollowed during the Accreditation Survey
Time frame worked out for the survey inTime frame worked out for the survey in
mutual consultationmutual consultation
ACCREDITATION SURVEYACCREDITATION SURVEY
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ACCREDITATION SURVEY ACCREDITATION SURVEY
Carried out by a team of AssessorsCarried out by a team of Assessors
depending upon the size, complexity anddepending upon the size, complexity and
facilities provided by the organisationfacilities provided by the organisation
Scope will include all standards relatedScope will include all standards related
functions and all patient care settingsfunctions and all patient care settings
Onsite survey will consider specific culturalOnsite survey will consider specific cultural
and legal factors which may influence orand legal factors which may influence orshape decisions regarding the provision ofshape decisions regarding the provision of
care and /or policies and procedurescare and /or policies and procedures
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METHODOLOGY OF SURVEYMETHODOLOGY OF SURVEY Initial presentation by the hospitalInitial presentation by the hospital
Document ReviewDocument Review
Adherence to statutory obligationsAdherence to statutory obligations
Visits to various areasVisits to various areas
Facility surveys and toursFacility surveys and tours
Random structured interviewsRandom structured interviews
INITIAL PRESENTATION BYINITIAL PRESENTATION BY
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INITIAL PRESENTATION BYINITIAL PRESENTATION BY
THE HOSPITALTHE HOSPITAL OrganogramOrganogram
Quality management TeamQuality management Team
Methodology followed for QualityMethodology followed for QualityImprovementImprovement
Facilities providedFacilities provided Inputs on resources provided for QualityInputs on resources provided for Quality
ImprovementImprovement
Identified high Risk Areas for patient careIdentified high Risk Areas for patient careand safetyand safety
Sentinel Events being monitoredSentinel Events being monitored
INITIAL PRESENTATION BYINITIAL PRESENTATION BY
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THE HOSPITALTHE HOSPITAL Key Monitoring IndicatorsKey Monitoring Indicators
ResourceResourceVolumeVolume
UtilizationUtilization
PerformancePerformance
Control chartsControl charts
Problems faced and remedial measuresProblems faced and remedial measures
undertaken/ being undertakenundertaken/ being undertaken
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OBSERVATIONSOBSERVATIONS
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OBSERVATIONSOBSERVATIONS
Facility SafetyFacility Safety
Level of compliance with laid down policies andLevel of compliance with laid down policies and
proceduresprocedures
BMW ManagementBMW Management
Standard PrecautionsStandard Precautions
Patient carePatient care
Fire SafetyFire Safety
Equipment ManagementEquipment Management
INTERVIEWINTERVIEW
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INTERVIEWINTERVIEW
Staff InterviewStaff Interview
To determine their level of awareness andTo determine their level of awareness and
compliance with organisation policies andcompliance with organisation policies andproceduresprocedures
To assess their awareness levels of theirTo assess their awareness levels of their
rights, privileges and patient rightsrights, privileges and patient rights
To determine their satisfaction levelsTo determine their satisfaction levels
Patient and family InterviewPatient and family Interview To assess their level of awareness of theTo assess their level of awareness of the
care process and their rightscare process and their rights
o determine their satisfaction levelso determine their satisfaction levels
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SCORING PATTERNSCORING PATTERN NABH has laid down the following patternNABH has laid down the following pattern
NonNon--compliancecompliance 00Partial compliancePartial compliance 55
Full complianceFull compliance 1010
No standard can have more than one zeroNo standard can have more than one zero
The average for a standard must exceed 5The average for a standard must exceed 5 The overall average score must exceed 7The overall average score must exceed 7
No zeros in legal requirementsNo zeros in legal requirements
OUTCOMES OF ACCREDITATIONOUTCOMES OF ACCREDITATION
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SURVEYSSURVEYS AccreditedAccredited
HCO shows acceptable compliance with laidHCO shows acceptable compliance with laid
down standards in all areasdown standards in all areas
Includes the scope of services for whichIncludes the scope of services for whichaccreditedaccredited
Any increase in scope the survey has to be Any increase in scope the survey has to be
done for the increased scopedone for the increased scope Accreditation deniedAccreditation denied
HCO is consistently non compliant withHCO is consistently non compliant with
standardsstandards
Accreditation withdrawnAccreditation withdrawn
HCO withdraws voluntarilyHCO withdraws voluntarily
Due to consistent non compliance or nonDue to consistent non compliance or non
adherence to safe and ethical practicesadherence to safe and ethical practices
DURATION OF ACCREDITATIONDURATION OF ACCREDITATION
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DURATION OF ACCREDITATIONDURATION OF ACCREDITATION
AWARDSAWARDS
Generally three years with one ReassessmentGenerally three years with one Reassessment
survey to ensure continued compliance and tosurvey to ensure continued compliance and to
assess the CQI programmeassess the CQI programme
If during accreditation NABH receives inputs thatIf during accreditation NABH receives inputs thatthe organisation is substantially out of compliancethe organisation is substantially out of compliance
with the current standards then Resurvey orwith the current standards then Resurvey or
withdrawal of accredited decision may be resortedwithdrawal of accredited decision may be resorted
toto
Summary of AccreditationSummary of Accreditation
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ProcessProcess
ApplicationsApplications Screening of the ApplicationsScreening of the Applications
PrePre--assessment surveyassessment survey
Assessment SurveyAssessment Survey
Review of the recommendations of theReview of the recommendations of the
assessing body by the Accreditationassessing body by the AccreditationCommitteeCommittee
Recommendations to the boardRecommendations to the board
Accreditation decisionAccreditation decision
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Brief Explanation of StandardsBrief Explanation of Standards
Access, Assessment and Continuity
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Access, Assessment and Continuity
Of Care (AAC)
The organization defines and displays the
services that it can provide.
Objective Elements
The services being provided are clearlydefined.
The defined services are prominentlydisplayed.
The staff is oriented to these services.
Admissions
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** Patients are accepted only if the organizationPatients are accepted only if the organization
can provide the required service.can provide the required service.
** TThe policies and procedures also addresshe policies and procedures also address
managing patients during non availability of beds.managing patients during non availability of beds.
Admissions
Transfer of patients
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* Transfer of unstable patients
* Transfer of stable patients
* Staff responsible during transfer
* Summary of patients condition and
the treatment given.
Assessment of patients
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Content of the assessments
Time frame within which the initial assessment
is completed
Initial assessment includes screening for
nutritional needs The initial assessment results in a documented
plan of care The plan of care also includes preventive
aspects of the care
Re-assessment
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All patients are reassessed at appropriate
intervals.
Staff involved in direct clinical care
document reassessments.
Patients are reassessed to determine their
response to treatment and to plan further
treatment or discharge.
Investigations
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* Adequately qualified and trained personnel
perform and/or supervise the investigations.
* Collection, identification, handling, safe
transportation, processing and disposal of
specimens.
* Laboratory / imaging results time frame.
* Critical results reporting
Investigations
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The laboratory / radiation safety program is
documented
Handling and disposal of infectious and
hazardous materials
Laboratory / imaging personnel are appropriately
trained in safe practices.
Laboratory / imaging personnel are provided
with appropriate safety equipment / devices.
Discharge
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Discharge process is planned
A discharge summary is given to all the
patients leaving the organization (including
patients leaving against medical advice)
Discharge
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Reasons for admission
Significant findings
Diagnosis
Patients condition at the time of discharge
Investigation results
Discharge
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Procedure performed, medication and
other treatment given
Follow up advice, medication and other
instructions in an understandable manner.
Instructions about when and how to obtain
urgent care
Patient records also contain a copy of the
discharge / case summary
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Patient Rights and EducationPatient Rights and Education
(PRE)(PRE)
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The organization protects patient and family rightsduring care
Objective Elements
Patient and family rights are documented
Patients and families are informed of their rights ina format and language that they can understand
The organizations leaders protect patients andfamily rights
Staff is aware of their responsibility in protectingpatients and family rights
Violation of patient and family rights is recorded,reviewed and corrective/preventive measures
taken
Rights
Respect for personal dignity and privacy
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Respect for personal dignity and privacy
Protection from physical abuse or neglect
Treating patient information as confidential
Refusal of treatment
Informed consent
Information and consent before any researchprotocol is initiated
Information on how to voice a complaint
Information on the expected cost of thetreatment
Access to his / her clinical records
Informed Consent
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Situations where informed consent is required
Informed consent includes
information on risks
Benefits
alternatives
Who will perform the requisite procedure in alanguage that they can understand
Who can give consent when patient isincapable of independent decision making
Education
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Safe and effective use of medication
Potential side effects of the medication
Diet and nutrition
Immunizations
Specific disease process, complications andprevention strategies
Preventing infections
Language and format that they canunderstand
Care Of Patients (COP)
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Care delivery is uniform when similar care is
provided in more than one setting
The care and treatment orders are signed,
named, timed and dated by the concerned doctor
The care plan is countersigned by the clinician in-
charge of the patient within 24 hours
Evidence based medicine and clinical practiceguidelines are adopted to guide patient care
whenever possible
Emergency servicesEmergency services
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Policies and procedure for emergency care are
documented
Policies also address handling of medico-legal cases
The patients receive care in consonance with the
policies
Policies and procedures guide the triage of patientsfor initiation of appropriate care
Staff is familiar with the policies and trained on the
procedures for care of Emergency patients Admission or discharge to home or transfer to another
organization is also Documented
Ambulance
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COP.3.The ambulance services are commensurate withthe scope of the services provided by the organization
Objective Elements
There is adequate access and space
Ambulance (s) is appropriately equipped
Ambulance (s) is manned by trained personnel
There is a checklist of all equipment and emergencymedications
Equipment are checked on a daily basis
Emergency medications are checked daily and prior todispatch
The ambulance(s) has proper communication system
CPR
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Documented policies and procedures guide theuniform use of resuscitation throughout the
organization
Staff providing direct patient care is trained and
periodically updated in cardio pulmonary
resuscitation
The events during a cardio-pulmonary
resuscitation are recorded
A post-event analysis of all cardiac arrests isdone by a multidisciplinary committee
Corrective and preventive measures are taken
n h - v n n l i
Blood transfusion
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Documented policies and procedures are usedto guide rational use of blood and bloodproducts
The transfusion services are governed by theapplicable laws and regulations
Informed consent is obtained for donation and
transfusion of blood and blood products
Informed consent also includes patient andfamily education about donation
Staff is trained to implement the policies
Transfusion reactions are analyzed for
preventive and corrective actions
ICUThe organization has documented admission and
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discharge criteria for its intensive care and highdependency units
Staff is trained to apply these criteria
Adequate staff and equipment are available
Defined procedures for situation of bed shortagesare followed
Infection control practices are followed
The unique needs of end of life patients are identifiedand cared for
A quality assurance program is implemented
Vulnerable patients Policies and procedures are documented and are
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in accordance with the prevailing laws and thenational and international guidelines
Care is organized and delivered in accordancewith the policies and procedures
The organization provides for a safe and secure
environment for this vulnerable group
A documented procedure exists for obtaining
informed consent from the appropriate legalrepresentative
Staff is trained to care for this vulnerable group
Obstetrics
P li i d d id h f hi h i k
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Policies and procedures guide the care of high riskobstetrical patients
The organization defines and displays whether high
risk obstetric cases can be cared for or not
Persons caring for high risk obstetric cases are
competent
High risk obstetric patients assessment also
includes maternal nutrition
The organization caring for high risk obstetric cases
has the facilities to take care of neonates of such
cases
Pediatrics
Th i ti d fi d di l th f
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The organization defines and displays the scope of
its pediatric services
The policy for care of neonatal patients is in
consonance with the national/ international guidelines
Those who care for children have age specific
competency
Provisions are made for special care of children
Pediatrics
Patient assessment includes detailed nutritional,
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growth, psychosocial and immunization
assessment
Policies and procedures prevent child/ neonate
abduction and abuse
The childrens family members are educated about
nutrition, immunization and safe parenting and this is
documented in the medical record
Sedation
Competent and trained persons perform sedationTh d i i t i d it i
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The person administering and monitoringsedation is different from the person performingthe procedure
Intra-procedure monitoring includes at a minimumthe heart rate, cardiac rhythm, respiratory rate,blood pressure, oxygen saturation, and level of
sedation Patients are monitored after sedation Criteria are used to determine appropriateness of
discharge from the recovery area Equipment and manpower are available to
rescue patients from a deeper level of sedation
than that intended
Anesthesia
All patients for anesthesia have a pre anesthesia
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All patients for anesthesia have a pre-anesthesia
assessment by a qualified individual
The pre-anesthesia assessment results in formulation
of an anesthesia plan which is documented
An immediate preoperative reevaluation is
documented
Informed consent for administration of anesthesia is
obtained by the anesthetist
Anesthesia
During anesthesia monitoring includes regular and
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periodic recording of heart rate, cardiac rhythm,
respiratory rate, blood pressure, oxygen saturation,
airway security and patency and level of anesthesia
Each patients post-anesthesia status is monitored
and documented
A qualified individual applies defined criteria to
transfer the patient from the recovery area All adverse anesthesia events are recorded and
monitored
Surgery
Surgical patients have a preoperative assessment
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Surgical patients have a preoperative assessmentand a provisional diagnosis documented prior tosurgery
An informed consent is obtained by a surgeon prior tothe procedure
Documented policies and procedures exist to preventadverse events like Wrong site, wrong patient and
wrong surgery
Persons qualified by law are permitted to perform theprocedures that they are entitled to perform
Surgery
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A brief operative note is documented prior totransfer out of patient from recovery area
The operating surgeon documents the post-operative plan of care
A quality assurance program is followed for thesurgical services
Standard
Policies and procedures guide the care of patients
Restraints
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Policies and procedures guide the care of patientsunder restraints (physical and / or chemical)
Objective Elements Documented policies and procedures guide the care of
patients under restraints
These include both physical and chemical restraintmeasures
These include documentation of reasons for restraints
These patients are more frequently monitored
Staff receive training and periodic updating in control
and restraint techniques
Pain management
Documented policies and procedures guide the
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Documented policies and procedures guide the
management of pain
The organization respects and supports the
appropriate assessment and management of pain for
all patients
Patient and family are educated on various pain
management techniques
End of life careStandard
COP 18 Policies and procedures guide the end of life
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COP.18. Policies and procedures guide the end of life
care
Objective Elements
Documented policies and procedures guide the end of
life care
These policies and procedures are in consonance with
the legal requirements
These also address the identification of the unique
needs of such patient and family These also include sensitively addressing issues such
as autopsy and organ donation
Staff is educated and trained in end of life care
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Management ofManagement of
Medication (MOM)Medication (MOM)
Drug committeeStandard
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Standard
Policies and procedures guide the organization of
pharmacy services and usage of medication
Objective Elements
There is a documented policy and procedure forpharmacy services and medication usage
These comply with the applicable laws and
regulations
A multidisciplinary committee guides the formulation
and im lementation of these olicies and rocedures
Formulary
Objective Elements
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Objective Elements
A list of medication appropriate for the
patients and organizations resources isdeveloped
The list is developed collaboratively by themultidisciplinary committee
There is a defined process for acquisition of
these medicationsThere is a process to obtain medications notlisted in the formulary
Storage of medication
Objective Elements
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Objective Elements
Documented policies and procedures exist for
storage of medication
Medications are stored in a clean, well lit and
ventilated environment
Sound inventory control practices guide
storage of the medications
Medications are protected from loss or theft
Storage of medication
Objective Elements
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Objective Elements
Sound alike and look alike medications are
stored separately
There is a method to obtain medication when
the pharmacy is closedEmergency medications are available all thetime
Emergency medications are replenished in atimely manner when used
Prescription of medications
Objective Elements
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Objective Elements
Documented policies and procedures exist for
prescription of medications
The organization determines who can write
orders
Orders are written in a uniform location in the
medical records
Medication orders are clear, legible, dated,
named and signed
Prescription of medications
Obj ti El t
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Objective Elements
Policy on verbal orders is documented and
implemented
The organization defines a list of high risk
medication
High risk medication orders are verified prior to
dispensing
Safe dispensing of medications
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Safe dispensing of medicationsObjective Elements
Documented policies and procedures guidethe safe dispensing of medications
The policies include a procedure for
medication recall
Expiry dates are checked prior to
dispensingLabeling requirements are documented andimplemented by the organization
Medication administration
Objective Elements
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Objective Elements
Medications are administered by those who are
permitted by law to do soPrepared medication are labeled prior to preparationof a second drug
Patient is identified prior to administration
Medication is verified from the order prior to
administration
Dosage is verified from the order prior toadministration
Medication administration
Objective Elements
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j
Route is verified from the order prior to
administrationTiming is verified from the order prior toadministration
Medication administration is documented
Polices and procedures govern patients selfadministration of medications
Polices and procedures govern patientsmedications brought from outside the
organization
Medication education
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Objective Elements
Patient and family are educated about safe and
effective use of medication
Patient and family are educated about food-
drug interactions
Medication effects
Objective Elements
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j
Patients are monitored after medication
administration and this is documentedAdverse drug events are defined
Adverse drug events are reported within aspecified time frame
Adverse drug events are collected and analyzedPolicies are modified to reduce adverse drugevents when unacceptable trends occur
Narcotic drugs and psychotropicsubstances
Objective Elements
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Objective Elements
Documented policies and procedures guidethe use of narcotic drugs and psychotropicsubstances
These policies are in consonance with localand national regulations
A proper record is kept of the usage,
administration and disposal of these drugsThese drugs are handled by appropriatepersonnel in accordance with policies
Chemotherapeutic agents
Objective Elements
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Documented policies and procedures guidethe usage of chemotherapeutic agents
Chemotherapy is prescribed by those whohave the knowledge to monitor and treat the
adverse effect of chemotherapy
Chemotherapy is prepared and administered
by qualified personnelChemotherapy drugs are disposed off inaccordance with legal requirements.
Radioactive or investigational drugs
Objective Elements
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Documented policies and procedures governusage of radioactive or investigational drugs
These policies and procedures are inconsonance with laws and regulations
The policies and procedures include the safestorage, preparation, handling, distributionand disposal of radioactive and investigationaldrugs
Staff, patients and visitors are educated on
safety precautions
Implantable prosthesis
Objective Elements
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Documented policies and procedures governprocurement and usage of implantableprosthesis
Selection of implantable prosthesis is based
on scientific criteria and internationallyrecognized approvals
The batch and serial number of the
implantable prosthesis are recorded in thepatients medical record and the masterlogbook
Medical gases
Objective Elements
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Documented policies and procedures govern
procurement, handling, storage, distribution,usage and replenishment of medical gases.
The policies and procedures address thesafety issues at all levels
Appropriate records are maintained inaccordance with the policies, procedures andlegal requirements.
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Hospital Infection Control (HIC)
Infection control programStandard
The organization has a well-designed, comprehensiveand coordinated Hospital Infection Control (HIC)
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and coordinated Hospital Infection Control (HIC)programme aimed at reducing/ eliminating risks topatients, visitors and providers of care.
Objective Elements
The hospital has a multi-disciplinary infection control
committee.The hospital has an infection control team.
The hospital has designated and qualified infection
control nurse(s) for this activityThe hospital infection control programme isdocumented.
Infection control manual
The manual identifies the various high-riskareas
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areas.
It outlines methods of surveillance in the
identified high-risk areas.
Focuses on adherence to standardprecautions at all times.
Equipment cleaning and sterilisation practices
An appropriate antibiotic policy is establishedand implemented.
Infection control manual
Laundry and linen management processes
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Laundry and linen management processes
are also included.
Kitchen sanitation and food handling issues
are included in the manual
Engineering controls to prevent infections
Mortuary practices and procedures are
included as appropriate to the organization
Surveillance
Objective Elements
Surveillance activities are appropriately directed
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pp p y
towards the identified high-risk areas.
Collection of surveillance data is an ongoingprocess.
Verification of data is done on regular basis by the
infection control team.
In cases of notifiable diseases, information (in
relevant format) is sent to appropriate authorities.Scope of surveillance activities incorporatestracking and analysing of infection risks, rates and
Hospital Associated Infections (HAI)
Objective Elements
The organization monitors urinary tract infections.
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The organization monitors urinary tract infections.
The organization monitors respiratory tract
infections.
The organization monitors intra-vascular device
infections.
The organization monitors surgical site infections.
Appropriate feedback regarding HAI rates areprovided on a regular basis to medical and nursing
staff.
Resources
Hand washing facilities in all patient careareas are accessible to health care
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areas are accessible to health careproviders.
Compliance with proper hand washing ismonitored regularly.
Isolation/ barrier nursing facilities areavailable.
Adequate gloves, masks, soaps, anddisinfectants are available and usedcorrectly.
Outbreaks of infections
Hospital has a documented procedure for handlingsuch outbreaks.
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This procedure is implemented during outbreaks.
After the outbreak is over appropriate correctiveactions are taken to prevent recurrence.
CSSD
There is adequate space available for sterilizationactivities
Regular validation tests for sterilisation are carried
out and documented.
There is an established recall procedure whenbreakdown in the sterilisation system is identified.
Bio-medical waste management
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Proper segregation and collection of Bio-medical Waste from all patient care areas ofthe hospital is implemented and monitored
Appropriate personal protective measures
are used by all categories of staff handling
Bio-medical Waste.
Staff training
The hospital regularly earmarks adequate funds
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p g y q
from its annual budget in this regard.
It conducts regular pre-induction training forappropriate categories of staff before joiningconcerned departments
It also conducts regular in-service trainingsessions for all concerned categories of staff atleast once in a year.
Appropriate pre and post exposure prophylaxis isprovided to all concerned staff members.
And You Thought You Had aAnd You Thought You Had a
MigraineMigraine
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UnfortunatelyUnfortunately
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UnfortunatelyUnfortunately
There isThere isMoreMore
ToTo
FollowFollow
SORRY !!!!!!SORRY !!!!!!
This is for all of youThis is for all of you--ourour
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yy
friends .friends .
20.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:32
Sometimes the pressureSometimes the pressure
Is so highIs so high
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Is so high...Is so high...
The hours are so long...The hours are so long...The problems so big...The problems so big...
The whole world seems toThe whole world seems to
be against you...be against you...Do you know what youDo you know what youshould do?should do?
Pretend that all that is not happening to you!Pretend that all that is not happening to you!
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Have fun!Have fun!
Act silly!Act silly!
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DonDont listen to the ones who maket listen to the ones who make
you feel depressed!you feel depressed!
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Smile!Smile!
Ignore your problems!Ignore your problems!
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Do what you enjoy!Do what you enjoy!
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Stop worrying!Stop worrying!
Be warm and loving!Be warm and loving!
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Make timeMake timefor the thingsfor the things
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for the thingsfor the things
you love!you love!
M k f fM k f f
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Make fun ofMake fun of
trouble!trouble!
Leave your fearsLeave your fears
aside and...aside and...
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Be a bit ridiculous!Be a bit ridiculous!
Fight forFight for
perfection...perfection...
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...but not to exhaustion!...but not to exhaustion!
Life is better when we have fun...Life is better when we have fun...
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...so do anything you like....so do anything you like.
And the mostAnd the most
importantimportant::
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Life doesnLife doesntt
end today...end today...
And doesnAnd doesnt start tomorrowt start tomorrow......
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DonDont stop!!t stop!!
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pp
Each minute of stressEach minute of stress
is wasted timeis wasted time
This is why I wish you:This is why I wish you:
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A little madness and a littleA little madness and a little
imagination, so you can see life betterimagination, so you can see life betterthan usual!!than usual!!
The End showThe End showThe End showThe End showThe End showThe End showThe End showThe End show20.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:3220.09.2008 10:32
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And donAnd dont forgett forget::
Smile!Smile!In life everything is nicer whenIn life everything is nicer when
you cheer up.you cheer up.
Because The Show Must GO ON!Because The Show Must GO ON!
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Continuous Quality ImprovementContinuous Quality Improvement
Structured Quality ImprovementStructured Quality Improvement
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ProgrammeProgramme-- Documented, developed ,maintainedDocumented, developed ,maintained
and updated by a multi disciplinaryand updated by a multi disciplinarycommitteecommittee
-- Communicated and coCommunicated and co ordinatedordinatedamongst all employeesamongst all employees
Continuous Quality ImprovementContinuous Quality Improvement
Key Indicators to monitor ClinicalKey Indicators to monitor ClinicalStructures , Processes and OutcomesStructures , Processes and Outcomes
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Structures , Processes and OutcomesStructures , Processes and Outcomes
-- Invasive ProceduresInvasive Procedures-- Diagnostic servicesDiagnostic services
--
Adverse drug EventsAdverse drug Events
-- Use ofUse ofAnaesthesiaAnaesthesia
-- Use of blood and Blood ProductsUse of blood and Blood Products
-- Infection control ActivitiesInfection control Activities-- Clinical researchClinical research
Continuous Quality ImprovementContinuous Quality Improvement
Key Indicators to monitor ManagerialKey Indicators to monitor Managerial
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Structures , Processes and OutcomesStructures , Processes and Outcomes
-- Medication ProcurementMedication Procurement
-- UtilisationUtilisation of facilitiesof facilities
-- Patient and Employee satisfactionPatient and Employee satisfaction
-- Adverse EventsAdverse Events
Continuous Quality ImprovementContinuous Quality Improvement
Established system of Clinical AuditEstablished system of Clinical Audit
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-- Participation of Medical StaffParticipation of Medical Staff
-- Defining of parametersDefining of parameters
-- Maintenance of patient and clinicianMaintenance of patient and clinician
anonymityanonymity
-- Documentation of AuditsDocumentation of Audits
-- Institution of remedial measuresInstitution of remedial measures
Continuous Quality ImprovementContinuous Quality Improvement
Sentinel events are intensivelySentinel events are intensively analysedanalysed
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-- Defining of sentinel eventsDefining of sentinel events
-- Established processes for intenseEstablished processes for intense
analysisanalysis
-- Corrective and Preventive measures areCorrective and Preventive measures are
undertaken based upon the analysisundertaken based upon the analysis
RESPONSIBILITIES OFRESPONSIBILITIES OF
MANAGEMENTMANAGEMENT
Responsibilities are definedResponsibilities are defined
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-- Documented organogramDocumented organogram
-- Appoint senior leadersAppoint senior leaders
-- Support QIPSupport QIP
-- Org complies with statutory obligationsOrg complies with statutory obligations
-- Address the org social responsibilitiesAddress the org social responsibilities
RESPONSIBILITIES OFRESPONSIBILITIES OF
MANAGEMENTMANAGEMENT
Services provided by each department areServices provided by each department are
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documenteddocumentedEach org programme ,service,Each org programme ,service,
department has effective leadershipdepartment has effective leadershipScope of services are definedScope of services are defined
AdmAdm policies and procedures arepolicies and procedures aremaintainedmaintained
RESPONSIBILITIES OFRESPONSIBILITIES OF
MANAGEMENTMANAGEMENT
Org is managed in an ethical mannerOrg is managed in an ethical manner
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-- Org discloses its ownershipOrg discloses its ownership
-- Honestly portrays the services that itHonestly portrays the services that it
can or cannot providecan or cannot provide
-- Accurately bills based upon a standardAccurately bills based upon a standard
tarifftariff
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FACILITIES MANAGEMENT ANDFACILITIES MANAGEMENT AND
SAFETYSAFETY
Org has a programme for clinical andOrg has a programme for clinical andsupport servicesupport service eqpteqpt managementmanagement
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-- Plans forPlans for eqpteqpt in a collaborative mannerin a collaborative mannerin accordance with the services providedin accordance with the services provided
-- AllAll eqpteqpt are inventoried and proper logsare inventoried and proper logs
maintainedmaintained-- Qualified and trained personnel operateQualified and trained personnel operateand maintain theand maintain the eqpteqpt
-- EqptEqpt are periodically inspected andare periodically inspected andcalibratedcalibrated
-- Preventive and breakdown MaintenancePreventive and breakdown MaintenancePlanPlan
FACILITIES MANAGEMENT ANDFACILITIES MANAGEMENT AND
SAFETYSAFETY
Org has provisions for safe water,Org has provisions for safe water,
electricity, medical gases and vacuumelectricity, medical gases and vacuum
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electricity, medical gases and vacuumelectricity, medical gases and vacuum
systemssystems
Org has plans for fire and non fireOrg has plans for fire and non fire
emergenciesemergencies
Org has plans for handlingOrg has plans for handling
communitycommunity emergencies,epidemicsemergencies,epidemicsand other disasters.and other disasters.
HUMAN RESOURCES MANAGEMENTHUMAN RESOURCES MANAGEMENT
Org has documented system ofOrg has documented system of
Human resource PlanningHuman resource Planning
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Human resource PlanningHuman resource Planning
-- Maintains an adequate number and mixMaintains an adequate number and mix
of staff to meet the needs of patientsof staff to meet the needs of patients
-- The required job specifications andThe required job specifications anddescriptions are well defined for eachdescriptions are well defined for each
category of staffcategory of staff
-- Org verifies the antecedents of theOrg verifies the antecedents of the
potential employeepotential employee
HUMAN RESOURCES MANAGEMENTHUMAN RESOURCES MANAGEMENT
SocialisationSocialisation and Orientation of theand Orientation of the
new employeesnew employees
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new employeese e p oyees
-- Orientation to the OrgOrientation to the Org
-- Awareness of hospital and departmentalAwareness of hospital and departmental
policies and procedurespolicies and procedures-- Awareness of his and patients rightsAwareness of his and patients rights
and responsibilitiesand responsibilities
-- Orientation to the service standards ofOrientation to the service standards of
the orgthe org
HUMAN RESOURCES MANAGEMENTHUMAN RESOURCES MANAGEMENT
Ongoing Programme for professionalOngoing Programme for professionaltraining and development of stafftraining and development of staff
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Performance Appraisal systemPerformance Appraisal systemDisciplinary ProceduresDisciplinary Procedures
Grievance handling MechanismGrievance handling MechanismHealth needs of employeesHealth needs of employees
Personal record of each staff memberPersonal record of each staff member Credentialing and PrivilegingCredentialing and Privileging
INFORMATION MANAGEMENTINFORMATION MANAGEMENT
SYSTEMSYSTEM
Info needs of the organisation areInfo needs of the organisation areidentifiedidentified
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Policies and procedures to meet thePolicies and procedures to meet theneeds exist and are in accordanceneeds exist and are in accordance
with the prevailing laws andwith the prevailing laws and
regulationsregulations
Org contributes to the data base ofOrg contributes to the data base of
other organisations in accordanceother organisations in accordancewith the law of the land.with the law of the land.
INFORMATION MANAGEMENTINFORMATION MANAGEMENT
SYSTEMSYSTEM
Effective Management of dataEffective Management of data
-- Formats areFormats are standardisedstandardised
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-- Procedures laid down for timely andProcedures laid down for timely and
accurateaccurate dissemination,storagedissemination,storage andand
retrieval of dataretrieval of data
-- Participation of staff in selecting,Participation of staff in selecting,
integrating andintegrating and utilisingutilising datadata
INFORMATION MANAGEMENTINFORMATION MANAGEMENT
SYSTEMSYSTEM
Complete and accurate MedicalComplete and accurate Medicalrecord for each patientrecord for each patient
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-- Every Record has a unique identifierEvery Record has a unique identifier-- Every entry is dated and timedEvery entry is dated and timed
-- The author of the entry can beThe author of the entry can be
identifiedidentified
-- The record provides chronological andThe record provides chronological and
updated account of patient careupdated account of patient care
INFORMATION MANAGEMENTINFORMATION MANAGEMENT
SYSTEMSYSTEM
Policies and procedures addressPolicies and procedures address
Confidentiality, Integrity and SecurityConfidentiality, Integrity and Security
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of Informationof Information
Policies and Procedures exist forPolicies and Procedures exist for
retention time of recordsretention time of records
Medical Audits are carried outMedical Audits are carried out
regularly.regularly.
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WHAT SHOULD WE DO?WHAT SHOULD WE DO?
Quality management TeamQuality management Team
Quality ManualQuality Manual
Various Policies and ProceduresVarious Policies and Procedures
Identify High Risk Areas for patientIdentify High Risk Areas for patient
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care and safetycare and safety Identify Sentinel Events forIdentify Sentinel Events for
monitoringmonitoring
Provide resources for QualityProvide resources for QualityImprovementImprovement
Alter Mind setAlter Mind set Identify gaps between what isIdentify gaps between what is
expected and what existsexpected and what exists
INITIAL PRESENTATION BYINITIAL PRESENTATION BY
THE HOSPITALTHE HOSPITAL OrganogramOrganogram
Quality management TeamQuality management Team
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Methodology followed for QualityMethodology followed for QualityImprovementImprovement
Facilities providedFacilities provided
Inputs on resources provided for QualityInputs on resources provided for QualityImprovementImprovement
Identified high Risk Areas for patient careIdentified high Risk Areas for patient care
and safetyand safety Sentinel Events being monitoredSentinel Events being monitored
DOCUMENT REVIEWDOCUMENT REVIEW
Quality ManualQuality Manual
Various Policies and ProceduresVarious Policies and Procedures
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Minutes of Meetings of various committeesMinutes of Meetings of various committees
Medical RecordsMedical Records
Medical / Nursing AuditMedical / Nursing Audit Adverse EventsAdverse Events
HAIHAI
Action Taken ReportsAction Taken Reports
OBSERVEOBSERVE
Facility SafetyFacility Safety
Level of compliance with laid downLevel of compliance with laid down
policies and procedurespolicies and procedures
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CPRCPR BMW ManagementBMW Management
Standard PrecautionsStandard Precautions
Patient carePatient care
HAIHAI
Fire SafetyFire Safety
Equipment ManagementEquipment Management
INTERVIEWINTERVIEW
Staff InterviewStaff Interview To determine their level of awareness andTo determine their level of awareness and
compliance with organisation policies andcompliance with organisation policies and
dd
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proceduresprocedures To assess the awareness levels of theirTo assess the awareness levels of their
rights, privileges and patient rightsrights, privileges and patient rights
To determine their satisfaction levelsTo determine their satisfaction levels
Patient and family InterviewPatient and family Interview
To assess their level of awareness of theTo assess their level of awareness of thecare process and their rightscare process and their rights
To determine their satisfaction levelsTo determine their satisfaction levels
Key Monitoring IndicatorsKey Monitoring Indicators ResourceResource
V lV l
MONITORMONITOR
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VolumeVolume UtilizationUtilization
PerformancePerformance
Control chartsControl charts
Problems faced and remedialProblems faced and remedial
measures undertaken/ beingmeasures undertaken/ being
undertakenundertaken
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STRENGTHSSTRENGTHS
Professionally competent staffProfessionally competent staff
W ll l id d li i dW ll l id d li i d
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Well laid down policies andWell laid down policies and
proceduresprocedures
Disciplined work forceDisciplined work force
By and Large known clienteleBy and Large known clientele
Supportive Top managementSupportive Top management
CHALLENGESCHALLENGES
Attitudinal ChangeAttitudinal Change
Removing blind spotsRemoving blind spots
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Creating a holistic approach toCreating a holistic approach to medimedi
care.care.
Overcoming constraintsOvercoming constraints
Making benchmarks for servicesMaking benchmarks for services
providedprovided
Im lementin A ro rammesImplementing QA programmes
EXPERIENCESEXPERIENCES
HCOsHCOs are very enthusiasticare very enthusiastic
Ill preparedIll prepared
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Ill preparedIll prepared
Initial preparation is shoddyInitial preparation is shoddy
Resources required initiallyResources required initially
Benefits have a longer gestationBenefits have a longer gestation
periodperiod
PROBLEMS AND CHALLENGESPROBLEMS AND CHALLENGES
Quality Consciousness at all levels will takeQuality Consciousness at all levels will taketimetime
Sustenance and consistency of efforts willSustenance and consistency of efforts will
be requiredbe required
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be requiredbe required Commitment on a consistent basisCommitment on a consistent basis
High rates of attrition will require repeatedHigh rates of attrition will require repeatedand continual trainingand continual training
Public Sector will take a longer time to getPublic Sector will take a longer time to get
into the processinto the process
Quality and consistency of assessors andQuality and consistency of assessors andassessmentsassessments
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Also Nothing IsAlso Nothing Is
ImpossibleImpossible
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ImpossibleImpossible
For,For,
ImpossibleImpossible
MeansMeans
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MeansMeans
IIM PossibleM Possible
Quality Norms and Accreditation??
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Response of Medical Fraternity
Expected ResponseExpected Response
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There was a man whoThere was a man who
had four sons.had four sons.
He wanted his sons toHe wanted his sons to
learn not to Judgelearn not to Judge
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learn not to Judgelearn not to Judge
things too quickly.things too quickly.
So he sent them eachSo he sent them each
on aon a quest,inquest,in turn,toturn,to
go and look at a peargo and look at a pear
tree that was a greattree that was a great
distance awaydistance away
The first son went in the
winter,
the second in the spring,th thi d i
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the second in the spring,the third in summer,
and the youngest son in the
fall.
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When they had all gone andWhen they had all gone and
come back, he called themcome back, he called them
together to describe what theytogether to describe what they
had seenhad seen
The first son said that the tree was ugly,bent, and twisted.
The second son said no it was covered
with green buds and full of promise.
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The third son disagreed; he said it was laden with blossomsThe third son disagreed; he said it was laden with blossomsThe third son disagreed; he said it was laden with blossomsThe third son disagreed; he said it was laden with blossomsthat smelled sothat smelled sothat smelled sothat smelled so
sweet and looked so beautiful, it was the most gracefulsweet and looked so beautiful, it was the most gracefulsweet and looked so beautiful, it was the most gracefulsweet and looked so beautiful, it was the most graceful
thing he had everthing he had everthing he had everthing he had ever
seen.seen.seen.seen.
The last son disagreed with all of them; he said it was ripeThe last son disagreed with all of them; he said it was ripeThe last son disagreed with all of them; he said it was ripeThe last son disagreed with all of them; he said it was ripe
andandandand
drooping with fruit, full of life anddrooping with fruit, full of life anddrooping with fruit, full of life anddrooping with fruit, full of life and fulfilmentfulfilmentfulfilmentfulfilment....
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p gp gp gp g
The man then explained to his sons that they wereThe man then explained to his sons that they wereThe man then explained to his sons that they wereThe man then explained to his sons that they were
all right, because theyall right, because theyall right, because theyall right, because they
had each seen but only one season in the tree'shad each seen but only one season in the tree'shad each seen but only one season in the tree'shad each seen but only one season in the tree's
life.life.life.life.
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He told them that you cannot judge a tree, or aHe told them that you cannot judge a tree, or aHe told them that you cannot judge a tree, or aHe told them that you cannot judge a tree, or aperson, by only one season,person, by only one season,person, by only one season,person, by only one season,
and that the essence of who they are and theand that the essence of who they are and theand that the essence of who they are and theand that the essence of who they are and the
pleasure, joy, and love thatpleasure, joy, and love thatpleasure, joy, and love thatpleasure, joy, and love thatcome from that life can only be measured atcome from that life can only be measured atcome from that life can only be measured atcome from that life can only be measured at
the end, when all the seasonsthe end, when all the seasonsthe end, when all the seasonsthe end, when all the seasons
are up.are up.are up.are up.
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pppp
If you give up when it'sIf you give up when it'sIf you give up when it'sIf you give up when it's
winter,winter,winter,winter,
you will miss the promise ofyou will miss the promise ofyou will miss the promise ofyou will miss the promise of
youryouryouryourspring, the beauty of yourspring, the beauty of yourspring, the beauty of yourspring, the beauty of your
summer,summer,summer,summer,
fulfillment of your fall.fulfillment of your fall.fulfillment of your fall.fulfillment of your fall.
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Don't let the pain of one season destroy theDon't let the pain of one season destroy theDon't let the pain of one season destroy theDon't let the pain of one season destroy the
joy of all the rest.joy of all the rest.joy of all the rest.joy of all the rest.
Don't judge life by one difficult season.Don't judge life by one difficult season.Don't judge life by one difficult season.Don't judge life by one difficult season.
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Persevere through thedifficult patches
and better times are sureto come
some time.
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Aspire to Inspire Before You Expire
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Live Simply Love Generously. Care
Deeply. Speak Kindly.Leave the Rest to God.
Happiness keeps YouSweet,
Trials keep You Strong,
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Sorrows keep You Human
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Success keeps You Glowing,
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But Only Effort and Faith keeps You Going
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Take the first stepsAndKeep the Effort Going
U WILL SOON FIND THE PATH
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And thesunshine willfollow
THE CURRENT STATUS OFTHE CURRENT STATUS OFACCREDITATION IN INDIAACCREDITATION IN INDIA
Initializing phase is over.Initializing phase is over.
Phase of consolidation.Phase of consolidation.
The initial steps have been difficult butThe initial steps have been difficult but
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The initial steps have been difficult butThe initial steps have been difficult but
the journey has begun.the journey has begun.
The journey has to continueThe journey has to continue..
Especially sinceEspecially since ------------------------------------------------------
ACCREDITATION IS A JOURNEYACCREDITATION IS A JOURNEY
ANDAND
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ANDAND
NOT A DESTINATION.NOT A DESTINATION.
BON VOYAGE !!!!!BON VOYAGE !!!!!
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BON VOYAGE !!!!!BON VOYAGE !!!!!
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